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In this session we will provide an overview of obesity as a chronic disease and outline causes and consequences.

Speaker notes

Some populations which typically follow slimmer build types, such as Asian populations, develop obesity-related conditions at lower BMI ranges than Caucasian populations. Research on how these risks are best assessed and influenced is still ongoing.

Speaker notes

Waist circumference can be used instead of BMI to explain increased cardiovascular and metabolic risk from central obesity.

Again, we see some ethnic variations in these risk categories, as shown in the lower table.

Importantly, relatively modest amounts of weight loss (around 5% body weight reduction) can lead to substantial reductions in central obesity (up to 30% in some studies) and hence improvements in metabolic health.

Speaker notes

Academic papers often refer to z-score rather than BMI percentile. BMI percentile is an easier term to use in clinical practice.

Speaker notes

Speaker notes

The underlying issue in this patient is sleep apnoea: lack of sleep is affecting Andrew’s energy levels and mood.

The barriers that Andrew is describing may trigger you to do a screening for sleep apnoea, or they may be a cue for you to do a screening for depression.

Knowing about these screening tools is very important. You don’t need to be an expert in doing all the different kinds of screening, but you do need to be aware of where you can refer patients to get them done.

Speaker notes

When having a conversation with a patient, you may have all or any of these random thoughts.

This is normal: what you need to remember is that you can talk to your team members about these issues – you do not need to handle them alone. Your team can help you to have these conversations with your patients.

Obesity is complex; these kinds of issues and barriers will arise. The trick is to get your thoughts organized and move forward with your patient, depending on what they are currently thinking and feeling.

3.
Assess
Assess obesity class and stage.
• Obesity class (I–III) is based on BMI and is a measure of
how big the patient is.
• Obesity stage (0–4) is based on the medical, mental and
functional impact of obesity and is a measure of how
healthy the patient is.
• Waist circumference provides additional information
regarding cardiometabolic risk.
Source: Obesity Canada, 5 As of Obesity Management

5.
Ethnicity makes a difference to risk from BMI
Black, Asian and other ethnic groups risk developing some
chronic conditions, such as type 2 diabetes, at a lower BMI than
Caucasians.
Risk ranges for these ethnic groups:
• adults with a BMI of 23 or more are at increased risk
(equivalent to overweight range risk);
• adults with BMI of 27.5 or more are at high risk (equivalent
to obese range risk).

8.
Assess (paediatrics)
• Assess obesity status and stage.
• Obesity status in children is defined using BMI growth charts specific
for age and gender.
• Obesity stage is based on the 4Ms (Mental, Mechanical, Metabolic
and Milieu), which quantify the impact of obesity on children’s
overall health.

11.
Use BMI percentile or z-score for children
• DO NOT use adult BMI
reference ranges for children.
• Child reference ranges vary
constantly, according to age,
sex and pubertal growth spurt.
• BMI percentile takes account of
this variation and so allows
comparison at different ages.
• z-score uses standard deviation
from the mean.

14.
Interpreting BMI for age
• A child whose weight is average for their height will have a BMI for age between the
25th and 75th percentiles.
• During childhood, children are still growing, e.g. bone and muscle mass. Caution is
therefore needed with regard to restrictive dieting.
• However, growing into one’s weight – the process of a child “stretching” by gaining
height while the rate of weight gain slows – is only possible if adult height has not yet
been reached.
• The idea of advising children about growing into their weight may be falsely reassuring
for the older primary school child, as the window for growth in height is less.
• Children who have reached full height require weight loss in order to normalize BMI.

29.
Mobility and functional limitations
• Obesity can lead to functional limitations and disabilities with age in
both men and women.
• It is important to assess patients with obesity for mobility issues prior
to recommending a PA programme.
• Weight-bearing exercise increases stress on joints and could be
challenging for patients with underlying arthritis in knees or hips.
• Adipose tissue can prevent a full range of motion.
• For some patients, land-based PA can be uncomfortable (tissue
movement, rubbing and skin tension).

30.
Weight bias barriers to PA
• Evidence suggests that some people with obesity avoid PA
activities in public facilities for fear of shame and blame.
• Fitness centres can exclude people based on economic, social
and appearance factors (McLaren et al., 2012).
• Some fitness professionals also have weight bias and endorse
negative stereotypes and beliefs that people with obesity are
lazy and to blame for their weight (Puhl & Wharton, 2007).
McLaren L, Rock MJ, McElgunn J. Social inequalities in body weight and physical activity: exploring the role of fitness centers. Res Q Exerc
Sport. 2012;83(1):94–102.
Puhl RM, Wharton CM. Weight bias: a primer for the fitness industry. ACSMS Health Fit J. 2007;11(3):7–11.

32.
Drivers of obesity can be barriers to weight management
• Patients may face barriers that affect self-efficacy,
confidence, emotions, thinking, and mental and physical
health.
• Consider what affects a patient’s ability to move forward.
• Barriers can arise in different phases of the weight
management process.
• These barriers need to be addressed differently in the
case of each patient.

33.
Example: barriers to setting goals
You are talking to Cathy about increasing her physical activity,
and before you even set a goal, she tells you about her situation:
Cathy works in an industrial area where there are no
pavements. She feels self-conscious about walking in her
neighbourhood.
• What is the barrier?
• What do you do to set some goals with Cathy?

34.
Example: barriers to implementing goals
Norm has set some goals to increase physical activity, but in a visit he
tells you that he has not been able to follow through. Barriers that come
up include:
His work schedule has changed; he now has lunch meetings to
attend and can no longer go for walks.
• What is the barrier?
• How do you have this conversation? How can you help Norm
with his goal-setting?

35.
Example: medical barriers
Andrew is experiencing low levels of energy, affecting his mood and
concentration. His organizational skills are also affected by his mood and
he is struggling to keep up with his physical activity. Walking on a treadmill
also caused plantar fasciitis and he is feeling pain when he walks for long
periods of time.
• What is the barrier?
• What conversation do you have with Andrew to help him address
these barriers?
• Hint: assessment of underlying medical issues may affect how a
patient starts new behaviours.

36.
What are you thinking?
• Mismatched expectations?
• What am I missing?
• Supportive environment?
• Knowledge gaps?
• Are they ready?
• What’s next?
• What is going on?
• Is this important?
• Is this the right time?
• Are they confident?
• Who else could help?
• Life changes?
• Realistic goals?

37.
Summary
• Assess obesity class and stage.
• Assess for obesity drivers, complications and barriers (the
4Ms).
• Assess for root causes of weight gain.
• Drivers of weight gain can be barriers to weight management
strategies.
• Once you know what is driving the weight gain, you can move
on to Advise.